Intrapartum care of healthy women and their babies ... - The BMJ

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BMJ 2014;349:g6886 doi: 10.1136/bmj.g6886 (Published 3 December 2014)

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Practice

PRACTICE GUIDELINES

Intrapartum care of healthy women and their babies: summary of updated NICE guidance 1

Vanessa Delgado Nunes senior research fellow and guideline lead , Maryam Gholitabar research 1 1 associate , Jessica Mai Sims project manager , Susan Bewley chair of the guideline development 2 group, honorary professor of complex obstetrics , On behalf of the Guideline Development Group National Collaborating Centre for Women’s and Children’s Health, Royal College of Obstetricians and Gynaecologists, London NW1 4RG, UK; Women’s Health Academic Department, Kings College London, London, UK

1 2

This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

The care that a woman receives during labour has the potential to affect the woman herself, both physically and emotionally, and the health of her baby in the short and longer term. Good communication, support, and compassion from staff, as well as having her wishes respected, can help her feel in control of what is happening and help make birth a positive experience for the woman and her birth companion(s).

About 700 000 women give birth in England and Wales each year. Most are healthy, have a straightforward pregnancy, go into labour spontaneously, and give birth to a single baby after 37 weeks of pregnancy. Uncertainty around consistent practice and the availability of new evidence necessitated an update of 2007 guidance from the National Institute for Health and Care Excellence (NICE) on intrapartum care.1 This article summarises the most recent recommendations from NICE on the care of healthy women who go into labour at term (37-41 weeks’ gestation) (Clinical Guideline CG190).2

Recommendations

NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Choosing the planned place of birth • Explain to both multiparous and nulliparous women who are at low risk of complications that giving birth is

generally very safe for the woman and her baby. (New recommendation.) [Based on high to very low quality evidence from randomised controlled trials, observational studies, and the experience and opinion of the Guideline Development Group (GDG).] • Explain to both multiparous and nulliparous women that they may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit (alongside an obstetric unit and not requiring ambulance transfer), or obstetric unit) and support them in their choice of setting, wherever that may be: -Advise low risk multiparous women that planning to give birth at home or in a midwifery led unit (freestanding or alongside) is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit (tables 1⇓ and 2⇓) -Advise low risk nulliparous women that planning to give birth in a midwifery led unit (freestanding or alongside) is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit. However, if they plan birth at home there is a small increase in the risk of an adverse outcome for the baby (tables 3⇓ and 4⇓). (New recommendation.) [Based on high to very low quality evidence from randomised controlled trials and observational studies and the experience and opinion of the GDG] • Boxes 1 and 2 outline medical conditions and obstetric and gynaecological factors that indicate increased risk. Women with these conditions or factors should consider planned birth at an obstetric unit.

Correspondence to: V Delgado Nunes [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions

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BMJ 2014;349:g6886 doi: 10.1136/bmj.g6886 (Published 3 December 2014)

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PRACTICE

The bottom line • The care that a woman receives during labour can affect the woman herself (physically and emotionally) and the health of her baby in the short and longer term • Maternity services should provide a model of care that supports one-to-one care in labour • Low risk mothers and babies do not benefit from birth in hospital obstetric units or from many previously “routine” but unindicated labour interventions • Clinicians need to be familiar with the evidence and able to talk non-judgmentally to women about their choices

• Healthcare service commissioners and providers should ensure that all four birth settings are available to all women (in the local area or in a neighbouring area). (New recommendation.) [Based on the experience and opinion of the GDG] • If the midwife or the woman would like further discussion about the choice of planned place of birth, arrange this with a senior midwife (consultant or supervisor of midwives) or a consultant obstetrician (or both) if there are obstetric issues. (New recommendation.) [Based on the experience and opinion of the GDG] • When discussing the woman’s choice of place of birth with her, do not disclose personal views or judgments about her choices. (New recommendation.) [Based on the experience and opinion of the GDG]

Women’s experience in all birth settings • Providers, senior staff, and all healthcare professionals should ensure that in all birth settings there is a culture of respect for each woman as an individual undergoing an important and emotionally intense life experience. The woman should be in control, listened to, and cared for with compassion. Appropriate informed consent should be sought. (New recommendation.) [Based on low to very low quality evidence from observational studies and the experience and opinion of the GDG] • Senior staff should demonstrate, through their own words and behaviour, appropriate ways of relating to and talking about women and their birth companion(s), and of talking about birth and the choices to be made when giving birth. (New recommendation.) [Based on low to very low quality evidence from observational studies, and the experience and opinion of the GDG]

One-to-one care in all birth settings • Maternity services should: -Provide a model of care that supports one-to-one care in labour for all women and -Benchmark services and identify overstaffing or understaffing by using workforce planning models or woman-to-midwife ratios (or both). (New recommendation.) [Based on very low quality evidence from observational studies, and the experience and opinion of the GDG]

Service organisation and clinical governance • Commissioners and providers should ensure that there are: -Robust protocols in place for transfer of care between settings. -Clear local pathways for the continued care of women who are transferred from one setting to another, including:

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Where this involves crossing provider boundaries (institutional boundaries, whether geographical or policy related, should not impede care or endanger women) Arrangements for occasions when the nearest obstetric or neonatal unit is closed to admissions or when the local midwifery led unit is full. (New recommendation.) [Based on the experience and opinion of the GDG]

Education and early assessment • Consider early assessment of labour by telephone triage provided by a dedicated triage midwife for all women. (New recommendation.) [Based on high to low quality evidence from randomised trials and the experience and opinion of the GDG] • Consider a face-to-face early assessment of labour for all low risk nulliparous women, either: -At home (regardless of planned place of birth) or -In an assessment facility in her planned place of birth (midwifery led unit or obstetric unit), comprising one-to-one midwifery care for at least one hour. (New recommendation.) [Based on moderate quality evidence from randomised trials and the experience and opinion of the GDG]

Latent or first stage of labour • Do not leave a woman in established labour on her own except for short periods or at the woman’s request. [Based on the experience and opinion of the GDG] • Do not carry out a speculum examination if it is certain that the membranes have ruptured. [Based on moderate and low quality evidence from observational studies and the experience and opinion of the GDG] • Do not offer or advise clinical intervention if labour is progressing normally and the woman and baby are well. [Based on the experience and opinion of the GDG]

• In all stages of labour, women who have left the normal care pathway because of the development of complications can return to it if the complication is resolved. [Based on the experience and opinion of the GDG]

Duration of the first stage • Inform women that although the length of established first stage of labour varies between women: -First labours last on average eight hours and are unlikely to last for longer than 18 hours -Second and subsequent labours last on average five hours and are unlikely to last for longer than 12 hours. [Based on low and very low quality evidence from observational studies and the experience and opinion of the GDG] Subscribe: http://www.bmj.com/subscribe

BMJ 2014;349:g6886 doi: 10.1136/bmj.g6886 (Published 3 December 2014)

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PRACTICE

Box 1: Medical conditions indicating increased risk Women with such conditions should be considered for planned birth at an obstetric unit (other conditions may indicate a need for individual assessment when planning place of birth)

Cardiovascular Confirmed cardiac disease Hypertensive disorders

Respiratory Asthma that requires an increase in treatment or hospital treatment Cystic fibrosis

Haematological Haemoglobinopathies: sickle cell disease, β thalassaemia major History of thromboembolic disorders Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100×109/L Von Willebrand’s disease Bleeding disorder in the woman or unborn baby Atypical antibodies that carry a risk of haemolytic disease of the newborn

Endocrinological Hyperthyroidism Diabetes

Infective Risk factors associated with group B streptococcus whereby antibiotics in labour would be recommended Hepatitis B or C with abnormal liver function tests HIV positive Toxoplasmosis under treatment Current active infection with chicken pox, rubella, genital herpes in the woman or baby Tuberculosis under treatment

Immunological Systemic lupus erythematosus Scleroderma

Renal Abnormal renal function Renal disease that needs supervision by a renal specialist

Neurological Epilepsy Myasthenia gravis Previous stroke

Gastrointestinal Liver disease associated with current abnormal liver function tests

Psychiatric Psychiatric disorder that needs current inpatient care

• Give ongoing consideration to the woman’s emotional and psychological needs, including her desire for pain relief. [Based on the experience and opinion of the GDG] • Encourage the woman to communicate her need for analgesia at any point during labour. [Based on the experience and opinion of the GDG]

Fetal monitoring during labour • Do not perform cardiotocography for low risk women in established labour. (New recommendation.) [Based on high and moderate quality evidence from randomised controlled trials] • Offer telemetry to any woman who needs continuous cardiotocography during labour. (New recommendation.) [Based on high and low quality evidence from randomised For personal use only: See rights and reprints http://www.bmj.com/permissions

trials and observational studies, and the experience and opinion of the GDG] • Do not make any decision about a woman’s care in labour on the basis of cardiotocography findings alone. (New recommendation.) [Based on the experience and opinion of the GDG]

Intrapartum interventions to reduce perineal trauma • Do not perform perineal massage in the second stage of labour. [Based on high quality evidence from randomised trials and the experience and opinion of the GDG] • Do not carry out a routine episiotomy during spontaneous vaginal birth. [Based on high quality evidence from

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BMJ 2014;349:g6886 doi: 10.1136/bmj.g6886 (Published 3 December 2014)

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PRACTICE

Box 2: Obstetric and gynaecological factors indicating increased risk Women with such factors should be considered for planned birth at an obstetric unit (other conditions may indicate a need for individual assessment when planning place of birth)

Previous complications Unexplained stillbirth or neonatal death, or death related to intrapartum difficulty Baby with neonatal encephalopathy Pre-eclampsia requiring preterm birth Placental abruption with adverse outcome Eclampsia Uterine rupture Primary postpartum haemorrhage requiring additional treatment or blood transfusion Retained placenta requiring manual removal in theatre Caesarean section Shoulder dystocia

Current pregnancy Multiple birth Placenta praevia Pre-eclampsia or pregnancy induced hypertension Preterm labour or preterm prelabour rupture of membranes Placental abruption Anaemia (haemoglobin